CMS Pub. 100-02, ch. 10, § 30.1.1

Basic Life Support (BLS)

Definition: BLS is transportation by ground ambulance vehicle (as defined in section

10.1, above) and the provision of medically necessary supplies and services (as defined in

section 10.2, above), including BLS ambulance services as defined by the state.

The ambulance vehicle must be staffed by at least two people who meet the requirements

of the state and local laws where the services are being furnished, and at least one of the

staff members must be certified at a minimum as an emergency medical technician-basic

(EMT-Basic) by the state or local authority where the services are being furnished and be

legally authorized to operate all lifesaving and life-sustaining equipment on board the

vehicle. These laws may vary from state to state or within a state.

Basic Life Support (BLS) – Emergency

Definition: When medically necessary, the provision of BLS services, as specified

above, in the context of an emergency response (as defined below).

Advanced Life Support, Level 1 (ALS1)

Definition: Advanced life support, level 1 (ALS1) is the transportation by ground

ambulance vehicle (as defined in section 10.1, above) and the provision of medically

necessary supplies and services (as defined in section 10.2, above) including the

provision of an ALS assessment by ALS personnel or at least one ALS intervention.

Advanced Life Support Assessment

Definition: An ALS assessment is an assessment performed by an ALS crew as part of

an emergency response (as defined below) that was necessary because the patient's

reported condition at the time of dispatch was such that only an ALS crew was qualified

to perform the assessment. An ALS assessment does not necessarily result in a

determination that the patient requires an ALS level of service. In the case of an

appropriately dispatched ALS Emergency service, as defined below, if the ALS crew

completes an ALS Assessment, the services provided by the ambulance transportation

service provider or supplier shall be covered at the ALS emergency level, regardless of

whether the patient required ALS intervention services during the transport, provided that

ambulance transportation itself was medically reasonable and necessary, as defined in

section 10.2, above and all other coverage requirements are met.

Advanced Life Support Intervention

Definition: An ALS intervention is a procedure that is in accordance with state and local

laws, required to be done by an emergency medical technician-intermediate (EMT-Intermediate) or EMT-Paramedic.

Application: An ALS intervention must be medically necessary to qualify as an

intervention for payment for an ALS level of service. An ALS intervention applies only

to ground transports.

Advanced Life Support, Level 1 (ALS1) - Emergency

Definition: When medically necessary, the provision of ALS1 services, as specified

above, in the context of an emergency response, as defined below.

Advanced Life Support, Level 2 (ALS2)

Definition: Advanced life support, level 2 (ALS2) is the transportation by ground

ambulance vehicle and the provision of medically necessary supplies and services

including (1) at least three separate administrations of one or more medications by

intravenous (IV) push/bolus or by continuous infusion (excluding crystalloid fluids) or

(2) ground ambulance transport, medically necessary supplies and services, and the

provision of at least one of the ALS2 procedures listed below:

a. Manual defibrillation/cardioversion;

b. Endotracheal intubation;

c. Central venous line;

d. Cardiac pacing;

e. Chest decompression;

f. Surgical airway; or

g. Intraosseous line; or

h. Prehospital blood transfusion which includes:

(i) Administration of low titer O+ and O- whole blood (WBT);

(ii) Administration of packed red blood cells (PRBCs);

(iii) Administration of plasma; or

(iv) Administration of a combination of PRBCs and plasma.

Application: Crystalloid fluids include but are not necessarily limited to 5 percent

Dextrose in water (often referred to as D5W), Saline and Lactated Ringer’s. To qualify

for the ALS2 level of payment, medications must be administered intravenously.

Medications that are administered by other means, for example: intramuscularly,

subcutaneously, orally, sublingually, or nebulized do not support payment at the ALS2

level rate.

The IV medications are administered in standard doses as directed by local protocol or

online medical direction. It is not appropriate to administer a medication in divided

doses in order to meet the ALS2 level of payment. For example, if the local protocol

for the treatment of supraventricular tachycardia (SVT) calls for a 6 mg dose of

adenosine, the administration of three 2 mg doses in order to qualify for the ALS 2 level

is not acceptable.

The administration of an intravenous drug by infusion qualifies as one intravenous

dose. For example, if a patient is being treated for atrial fibrillation in order to slow the

ventricular rate with diltiazem and the patient requires two boluses of the drug followed

by an infusion of diltiazem, then the infusion would be counted as the third intravenous

administration and the transport would be billed as an ALS 2 level of service.

The fractional administration of a single dose (for this purpose, meaning a “standard” or

“protocol” dose) of a medication on three separate occasions does not qualify for ALS2

payment. In other words, the administering 1/3 of a qualifying dose 3 times does not

equate to three qualifying doses to support claiming ALS2-level care. For example,

administering one-third of a dose of X medication 3 times might = Y (where Y is a

standard/protocol drug amount), but the same sequence does not equal 3 times Y.

Thus, if 3 administrations of the same drug are required to claim ALS2 level care, each

administration must be in accordance with local protocols; the run will not qualify at the

ALS2 level on the basis of drug administration if that administration was not according

to local protocol. The criterion of multiple administrations of the same drug requires

that a suitable quantity of the drug be administered and that there be a suitable amount

of time between administrations, and that both are in accordance with standard medical

practice guidelines.

An example of a single dose of medication administered fractionally on three separate

occasions that would not qualify for the ALS2 payment rate is the administration of a

single 1 mg dose of IV Epinephrine in partial increments to treat an adult pulseless

Ventricular Tachycardia/Ventricular Fibrillation (VF/VT) patient. The American Heart

Association (AHA), Advanced Cardiac Life Support (ACLS) protocol calls for

Epinephrine to be administered in 1 mg increments every 3 to 5 minutes. Therefore,

administering IV Epinephrine in separate increments of 0.25 mg, 0.25 mg, and 0.50 mg

(for a total of 1 mg) over the course of a single 3 to 5 minute episode would not qualify

for the ALS2 level of payment. Conversely, administering three separate 1 mg doses of

IV Epinephrine over the requisite protocol-based time period to a patient with

unresolved VF/VT would qualify for an ALS2 level of service. NOTE: refer to and

abide by your authorized protocols; AHA’s ACLS protocols are referenced here only

by way of widely recognized example.

Another example that would not qualify for the ALS2 payment level is administering

Adenosine in three 2 mg increments (for a total of 6 mg) in treating an adult patient

with Paroxysmal Supraventricular Tachycardia (PSVT). ACLS guidelines dictate

treating PSVT with 6 mg of Adenosine by rapid intravenous push (IVP) over 1 to 2

seconds. Should the initial 6 mg dose not eliminate the PSVT within 1 to 2 minutes,

guidelines dictate that another 12 mg of Adenosine IVP should be administered where

the PSVT persists, followed by another 12 mg dose 1 to 2 minutes later; for a total of 30

mg of Adenosine. Administering a total of 30 mg of Adenosine, involving three

episodes of administration in a complete cycle of treatment as outlined above, would

qualify for ALS2 payment.

Endotracheal (ET) intubation (which includes intubating and/or monitoring/maintaining

an ET tube inserted prior to transport) is a service that qualifies for the ALS2 level of

payment. Therefore, it is not necessary to consider medications administered by ET

tube to determine whether the ALS2 rate is payable.

The administration of PHBTs requires an individual trained to the level of the

emergency medical technician -intermediate [EMT-Intermediate] or paramedic.

Medical monitoring of WBT by an EMT-Intermediate or paramedic with additional

training to administer WBT during a ground ambulance transport would qualify for

ALS2 payment.

Advanced Life Support (ALS) Personnel

Definition: ALS personnel are individuals trained to the level of the emergency medical

technician-intermediate (EMT-Intermediate) or paramedic.

Specialty Care Transport (SCT)

Definition: SCT is the interfacility transportation (as defined below) of a critically

injured or ill beneficiary by a ground ambulance vehicle, including the provision of

medically necessary supplies and services, at a level of service beyond the scope of the

EMT-Paramedic. SCT is necessary when a beneficiary’s condition requires ongoing care

that must be furnished by one or more health professionals in an appropriate specialty

area, for example, emergency or critical care nursing, emergency medicine, respiratory

care, cardiovascular care, or an EMT-Paramedic with additional training.

Application: SCT is necessary when a beneficiary’s condition requires ongoing care that

must be furnished by one or more health professionals in an appropriate specialty area.

The EMT-Paramedic level of care is set by each state. Medically necessary care that is

furnished at a level above the EMT-Paramedic level of care may qualify as SCT. To be

clear, if EMT-Paramedics - without specialty care certification or qualification - are

permitted to furnish a given service in a state, then that service does not qualify for SCT.

The phrase “EMT-Paramedic with additional training” recognizes that a state may permit

a person who is not only certified as an EMT-Paramedic, but who also has successfully

completed additional education as determined by the state in furnishing higher level

medical services required by critically ill or injured patients, to furnish a level of service

that otherwise would require a health professional in an appropriate specialty care area

(for example, a nurse) to provide. “Additional training” means the specific additional

training that a state requires a paramedic to complete in order to qualify to furnish

specialty care to a critically ill or injured patient during an SCT.

Paramedic Intercept (PI)

Definition: Paramedic Intercept services are ALS services provided by an entity that does

not provide the ambulance transport. This type of service is most often provided for an

emergency ambulance transport in which a local volunteer ambulance that can provide

only BLS level of service is dispatched to transport a patient. If the patient needs ALS

services such as EKG monitoring, chest decompression, or IV therapy, another entity

dispatches a paramedic to meet the BLS ambulance at the scene or once the ambulance is

on the way to the hospital. The ALS paramedics then provide services to the patient.

This tiered approach to life saving is cost effective in many areas because most volunteer

ambulances do not charge for their services and one paramedic service can cover many

communities. Prior to March 1, 1999, Medicare payment could be made for these

services, but could not be made directly to the intercept service provider; rather,

Medicare payment could be made only when the claim was submitted by the entity that

actually furnished the ambulance transport. In those areas where state laws prohibited

volunteer ambulances from billing Medicare and other health insurance, the intercept

service could not receive payment for treating a Medicare beneficiary and was forced to

bill the beneficiary for the entire service.

Paramedic intercept services furnished on or after March 1, 1999, are payable separate

from the ambulance transport when all of the requirements in the following three

conditions are met:

I. The intercept service(s) is:

• Furnished in a rural area (as defined below);

• Furnished under a contract with one or more volunteer ambulance services;

and,

• Medically necessary based on the condition of the beneficiary receiving the

ambulance service.

II. The volunteer ambulance service involved must:

• Meet Medicare’s certification requirements for furnishing ambulance services;

• Furnish services only at the BLS level at the time of the intercept; and,

• Be prohibited by state law from billing anyone for any service.

III. The entity furnishing the ALS paramedic intercept service must:

• Meet Medicare’s certification requirements for furnishing ALS services, and,

• Bill all recipients who receive ALS paramedic intercept services from the

entity, regardless of whether or not those recipients are Medicare

beneficiaries.

For purposes of the paramedic intercept benefit, a rural area is an area that is designated

as rural by a state law or regulation or that is located in a rural census tract of a

metropolitan statistical area (as determined under the most recent version of the

Goldsmith Modification). (The Goldsmith Modification is a methodology to identify

small towns and rural areas within large metropolitan counties that are isolated from

central areas by distance or other features). The current list of these areas is periodically

published in the Federal Register.

See Pub. 100-04, Medicare Claims Processing Manual, Chapter 15, "Ambulance,"

§20.1.4 for payment of paramedic intercept services.

Services in a Rural Area

Definition: For purposes other than the paramedic intercept benefit (as defined above),

services in a rural area are services that are furnished (1) in an area outside a

Metropolitan Statistical Area (MSA); or, (2) an area identified as rural using the most

recent version of the Goldsmith Modification even though the area is within an MSA.

Emergency Response

Definition: Emergency response is a BLS or ALS1 level of service that has been

provided in immediate response to a 911 call or the equivalent. An immediate response is

one in which the ambulance provider/supplier begins as quickly as possible to take the

steps necessary to respond to the call.

The nature of an ambulance’s response (whether emergency or not) does not

independently establish or support medical necessity for an ambulance transport. Rather,

Medicare coverage always depends on, among other things, whether the service(s)

furnished is actually medically reasonable and necessary based on the patient’s condition

at the time of transport.

Application: The phrase “911 call or the equivalent” is intended to establish the standard

that the nature of the call at the time of dispatch is the determining factor. Regardless of

the medium by which the call is made (e.g., a radio call could be appropriate) the call is

of an emergent nature when, based on the information available to the dispatcher at the

time of the call, it is reasonable for the dispatcher to issue an emergency dispatch in light

of accepted, standard dispatch protocol. An emergency call need not come through 911

even in areas where a 911 call system exists. However, the determination to respond

emergently with a BLS or ALS ambulance must be in accord with the local 911 or

equivalent service dispatch protocol. If the call came in directly to the ambulance

provider/supplier, then the provider’s/supplier’s dispatch protocol and the dispatcher’s

actions must meet, at a minimum, the standards of the dispatch protocol of the local 911

or equivalent service. In areas that do not have a local 911 or equivalent service, the

protocol and the dispatcher’s actions must meet, at a minimum, the standards of the

dispatch protocol in another similar jurisdiction within the state, or if there is no similar

jurisdiction, then the standards of any other dispatch protocol within the state. Where the

dispatch was inconsistent with this standard of protocol, including where no protocol was

used, the beneficiary’s condition (for example, symptoms) at the scene determines the

appropriate level of payment.

EMT-Intermediate

Definition: EMT-Intermediate is an individual who is qualified, in accordance with state

and local laws, as an EMT-Basic and who is also certified in accordance with state and

local laws to perform essential advanced techniques and to administer a limited number

of medications.

EMT-Paramedic

Definition: EMT-Paramedic possesses the qualifications of the EMT-Intermediate and,

in accordance with state and local laws, has enhanced skills that include being able to

administer additional interventions and medications.

Interfacility Transportation

Definition: For purposes of SCT payment, an interfacility transportation is one in which

the origin and destination are one of the following: a hospital or skilled nursing facility

that participates in the Medicare program or a hospital-based facility that meets

Medicare’s requirements for provider-based status.